Miscarriage Flashcards
Define miscarriage.
spontaneous loss of a pregnancy before 24w of gestation.
Early: before 13w of gestation.
Late: 13 - 24w of gestation.
What is a threatened miscarriage?
Painless PV bleeding in the presence of a viable pregnancy in first 24w
Bleeding often less than menstruation
Os closed
What is a recurrent miscarriage?
spontaneous consecutive loss of 3 pregnancies before 24w of gestation.
What is complete miscarriage?
all POC have been expelled from the uterus + bleeding has stopped.
What is incomplete miscarriage?
non-viable pregnancy in which bleeding has begun but POC remains in the uterus.
Pain + PV bleeding
Os open
What is inevitable miscarriage?
non-viable pregnancy in which bleeding has begun + os is open, but POC remains in the uterus.
Heavy bleeding with clots + pain
Leads to incomplete or complete miscarriage.
What is missed miscarriage?
Non viable pregnancy identified on USS
No pain or bleeding
AKA delayed or silent miscarriage
What advice should be given if the woman is <6 weeks pregnant and is bleeding but not in pain?
Expectant Mx
Repeat pregnancy test after 7–10d
Return if test is +ve or if her Sx continue or worsen
-ve test means the pregnancy has miscarried.
What is the diagnostic tool of choice to assess the location and viability of the pregnancy?
TVUSS
What is the aetiology of miscarriage? What are risk factors for miscarriage?
Majority occur in 1st trimester
Most common cause: chromosome abnormality.
No cause of recurrence can be determined in ~50% of couples
What are signs and symptoms of miscarriage?
Pain
PV bleeding
Clotting
Open cervical os
What investigations should be carried out to confirm miscarriage?
Transvaginal USS: Empty fetal sac measuring >45mm OR fetal pole measuring >7mm without fetal heartbeat
Blood hCG - hCG should double every day - if it is not it is a miscarriage, if it is rising every day but not double it is ectopic
What symptoms of ectopic should be screened for in women with PV bleeding that are/ could be <15w pregnant?
Abdo or pelvic pain.
Gastro Sx: N+V
Dizziness, fainting or syncope.
Shoulder tip pain.
Urinary Sx
Passage of tissue.
Rectal pressure or pain on defecation
What signs of ectopic should be screened for in women with PV bleeding?
Abdominal tenderness
Pelvic tenderness
Adnexal tenderness.
Give 2 pregnancy-related conditions that can cause bleeding in the 1st +2nd trimesters
Ectopic
Molar pregnancy
Give 3 features that may indicate a molar pregnancy
Bleeding heavy + prolonged
Sx of pregnancy exaggerated
Uterus large for dates
Give 3 pregnancy-related conditions that can cause abdominal pain in the 1st + 2nd trimesters
Ruptured ovarian corpus luteal cyst.
Adnexal torsion.
Pregnancy-related degeneration of a fibroid “red degeneration”
List 6 non-pregnancy-related conditions that can cause bleeding in early pregnancy
Cervicitis, cervical ectropion, or cervical polyps.
Haemorrhoids
TRAUMA of cervix, vagina, or vulva.
Urethral bleeding.
Vaginitis.
CANCER of cervix, vagina, or vulva.
Give 6 non-pregnancy-related conditions that can cause abdominal pain in early pregnancy
MSK pain
Gastro: IBS, constipation
UTI/ Renal colic
PID
Ovarian cyst
Torsion of a fibroid
Which symptoms in combination with a positive pregnancy test require immediate admission to early pregnancy unit?
Abdominal pain + tenderness, or
Pelvic tenderness, or
Cervical motion tenderness.
If there is no abdominal pain and tenderness, pelvic/ cervical motion tenderness and the woman is >,6w pregnant or of uncertain gestation how should they be managed?
Refer to early pregnancy assessment unit
(urgency of referral depends on clinical presentation)
When should you arrange immediate ambulance transfer to hospital for a woman presenting with bleeding or any other Sx suggestive of an early pregnancy complication ?
If haemodynamic instability: pallor, tachycardia, hypotension, shock, + collapse.
If significant concern about the degree of bleeding or pain.
What happens if viability of an IU pregnancy can’t be established because the fetus is of insufficient size for a heartbeat to be visualized?
Repeat after min. 7d
How should women with threatened miscarriage be managed?
If bleeding worsens, or persists beyond 14d, she should have a further clinical assessment.
If bleeding stops, she should start or continue routine antenatal care.
What is conservative management for miscarriage?
If bleeding + pain settle (suggesting complete miscarriage), take a pregnancy test after 3w
Return to the hospital if it is positive.
Offer medical/ surgical Mx if >14d persistent Sx
In which 4 scenarios is conservative management inappropriate?
Increased risk of haemorrhage (e.g. pregnancy is in late 1st trimester)
Previous adverse +/or traumatic experience a/w pregnancy: stillbirth, miscarriage, or APH
Increased risk from effects of haemorrhage: coagulopathy or is unable to have a blood transfusion
Evidence of infection.
What is the medical management for miscarriage?
Misoprostol: oral or PV
Pregnancy test after 3w + return if positive.
What is the mechanism of action of misoprostol in the management of miscarriage?
Prostaglandin analogue, binds to myometrial cells
Causes strong myometrial contractions leading to the expulsion of tissue
When may surgical management of miscarriage be more appropriate?
If RPOC despite medical Tx
or
if ongoing Sx after 14 days of expectant Mx
What are the options for surgical management of miscarriage?
Vacuum aspiration: LA as OP. “Suction curettage”
Surgical Mx in Theatre: GA “evacuation of RPOC”
When should anti D be given? (10)
Invasive prenatal dx: amniocentesis, CVS
APH
ECV of fetus (inc. attempted).
Ectopic (regardless of Mx)
Evacuation of molar pregnancy.
Intrauterine death + stillbirth.
Intrauterine procedures (eg, insertion of shunts, embryo reduction).
Miscarriage or threatened miscarriage >12w gestation.
Therapeutic TOP (regardless of gestation, inc. Miscarriage <12w with med/ surgical Mx)
Delivery: normal, instrumental or caesarean section.
What are complications of a miscarriage?
Incomplete evacuation of the uterus can result in placenta accreta in subsequent pregnancies
Post-evacuation uterine bleeding
Recurrent miscarriage
Asherman’s syndrome
Psychological dysfunction
When can women try again for a baby?
After the first negative pregnancy test, wait one cycle.
What are risk factors for miscarriage?
Maternal age
Previous miscarriage
Paternal age
What is an ectopic pregnancy?
fertilised ovum implanting + maturing outside the uterine cavity.
Where do most ectopics implant?
Ampulla of fallopian tube
Where are ectopic pregnancies more dangerous?
Isthmus
Give 7 RFs for ectopic pregnancy
Tubal damage: PID, surgery
Previous ectopic
Endometriosis
IUCD
POP
Maternal age >35y
Smoking
No identifiable cause in 1/3
Give 3 complications of ectopic pregnancy
Tubal rupture (potentially fatal if Tx is delayed).
Recurrent ectopic pregnancy.
Grief, anxiety, or depression.
Give 6 symptoms of ectopic pregnancy
6-8w amenorrhoea
Lower abdo pain (constant +/- unilateral)
PV bleeding (less than normal period)
Shoulder tip pain/ pain on defecation/ urination (peritoneal bleeding)
Dizziness, fainting, syncope
Sx of pregnancy- breast tenderness
Give 2 signs of ectopic pregnancy
Pelvic + abdominal tenderness.
Cervical excitation
What should be avoided when examining a patient with suspected ectopic?
DONT palpate for an adnexal or pelvic mass as this may increase the risk of rupture of an ectopic pregnancy if present.
Where are women with a suspected ectopic pregnancy managed?
Stable: Investigated + managed in EPAU
Unstable: refer to ED
What is the investigation of choice for an ectopic pregnancy?
TVUSS
(Pregnancy test: +ve)
Which criteria must be fulfilled for an ectopic pregnancy to be managed expectantly?
<35mm
Unruptured
Asymptomatic
No fetal heartbeat
hCG <1000 IU/L
Which criteria must be fulfilled for an ectopic pregnancy to be managed medically?
<35mm
Unruptured
No significant pain
No fetal heartbeat
hCG <1500 IU/L
Which criteria must be fulfilled for an ectopic pregnancy to be managed surgically?
> 35mm
Can be ruptured
Pain
Visible fetal heartbeat
hCG >5000 IU/L
Which forms of management are compatible with another intrauterine pregnancy?
Expectant
Surgical
What does expectant management of ectopic involve?
close monitoring over 48h
If B-hCG levels rise again or Sx manifest intervention is performed.
What is medical management of ectopic?
Methotrexate (parenteral)
Patient must attend f/u
What is surgical management of ectopic?
Salpingectomy: 1st line if no other RF for infertility
Salpingotomy: consider if RFs for infertility e.g. contralateral tube damage
What is salpingectomy and salpingotomy?
Salpingectomy: Fallopian tube removal
Salpingotomy: incision. Preservation of tube.
What is termination of pregnancy?
Medical/ surgical way of ending a pregnancy
What are the requirements for TOP to be legal?
Before 24w
2 registered medical practitioners must sign a legal document (in an emergency only 1 is needed)
Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
How quickly should TOP be performed?
Should not have to wait >2w from 1st referral to time of abortion.
Give 5 contraindications to medical TOP
Known/ suspected ectopic pregnancy
Previous allergic reaction to mifepristone or misoprostol
Severe uncontrolled asthma
Chronic adrenal failure
Inherited porphyria
What is medical TOP?
Mifepristone followed 48h later by misoprostal
What is the MOA of Mifepristone and Misoprostal?
Mifepristone: anti-progesterone- cervical ripening + sensitisation to prostaglandin induced contractions
Misoprostal: Prostaglandin analogue- stimulates uterine contraction
Where is medical TOP performed?
<12w: At home
>12w: medical facility preferred
What is the most effective regimen for medical TOP?
Mifepristone 200mg orally, followed 24–48h later by
Misoprostol 800 micrograms taken by the vaginal, buccal or sublingual route.
In medical TOP, if expulsion of the pregnancy has not occurred within 4h, what should be done?
A further 400 micrograms of misoprostol should be taken by the vaginal, buccal or sublingual route.
What is surgical TOP?
<14w: vacuum aspiration
> 14w: dilation + evacuation
What is vacuum aspiration for TOP?
Cervical preparation
If <14w can be done with LA if chosen (or sedation/ GA)
What is dilation + evacuation for TOP?
Cervical preparation
GA
Forceps + vacuum aspiration
Safest + most effective method >14w
What preparation is required before surgical TOP?
<12w: Mifepristone or Misoprostal
>12w: Mifepristone + Misoprostal + Osmotic dilators
What dose of anti-D should be given if <20w gestation?
250 IU
No need to screen for FMH
What dose of anti-D should be given if >20w gestation?
500 IU
Kleihauer test required
